www.healthywayrx.com

Customer Registration Information To register, fill in the form below. Items listed in bold must not be left blank. All information will be kept strictly confidential.

Personal Information:
Shopper's Login ID:	The name for login online to track orders.
Password	8 to 25 characters or numbers.
Verify Password	Match exactly.
Challenge Question	Reset password question.
Challenge Answer	Reset password answer.
Title
Last Name
First Name
Middle Name
Birth date	DD/MM/YYYY
Gender


Contact Information:
Address (line 1)
Address (line 2)
City
State
Zip
Country
Home Phone Number	only digits, no space. eg.1234446666
Contact Phone Number	only digits, no space. eg.1234446666
Fax Number	only digits, no space. eg.1234446666
E-mail
Best Time to Call

Doctor Information:
Doctor's Last Name
Doctor's First Name
Doctor's Phone Number	only digits, no space. eg.1234446666
Doctor's Fax Number	only digits, no space. eg.1234446666
Doctor's E-mail
Select one:	Doctor phone/fax your prescription Pharmacy calls your doctor

You are now ready to submit your registration for approval. To submit your registration, click the Submit button. Prior to submitting my personal profile, I acknowledge that I have read the following Limitation of Liability and Disclaimer and agree that: 1. The information available through this site is intended to assist in selecting non-prescription products and does not suggest diagnosis or treatment. This information is not a substitute for medical advice, treatment or attention. 2. I understand that neither Pharmacy nor this website has made any representations or warranties whatsoever. Without limiting the generality of the foregoing, neither Pharmacy nor this website has provided any representations or warranties of merchantability, fitness for a particular purpose or diagnosis. Further, neither Pharmacy nor this website represent or warrant that the information accessible on this website is accurate, complete or current. 3. Price and availability information is subject to change without notice. 4. Except as specifically stated on this site, neither Pharmacy nor any of its officers, directors, employees, agents or representatives will be liable for any damages of any kind arising out of, or in connection with, the use of this website. Without limiting the generality of the foregoing, there shall be no liability for damages of any kind including compensatory, direct, indirect or consequential damages for personal injury of any kind or for any reasons, including for loss of data, income or profit, loss of or damage to property and claims of third parties. The use of this website and all agreements relating thereto are subject to the terms and conditions of use published in the website.